Transcription of ISPD GUIDELINES/RECOMMENDATIONS
1 Peritoneal Dialysis International, Vol. 25, pp. 107 131 Printed in Canada. All rights $ + .00 Copyright 2005 International Society for Peritoneal Dialysis107 ISPD GUIDELINES/RECOMMENDATIONSPERITONEAL DIALYSIS-RELATED INFECTIONSRECOMMENDATIONS: 2005 UPDATEBeth Piraino,1 George R. bailie ,2 Judith Bernardini,1 Elisabeth Boeschoten,3 Amit Gupta,4 CliffordHolmes,5 Ed J. Kuijper,6 Philip Kam-Tao Li,7 Wai-Choong Lye,8 Salim Mujais,5 David L. Paterson,9 Miguel Perez Fontan,10 Alfonso Ramos,11 Franz Schaefer,12 and Linda Uttley13 Renal Electrolyte Division,1 University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania;Albany College of Pharmacy,2 Albany, New York, USA; Hans Mak Institute,3 Naarden, The Netherlands;Sanjay Gandhi Postgraduate Institute of Medical Sciences,4 Lucknow, India; Renal Division,5 BaxterHealthcare Corporation, McGaw Park, Illinois, USA; Department of Medical Microbiology,6 University MedicalCenter, Leiden, The Netherlands; Department of Medicine & Therapeutics,7 Prince of Wales Hospital,Chinese University of Hong Kong, Hong Kong; Centre for Kidney Diseases,8 Mount Elizabeth MedicalCentre, Singapore.
2 Division of Infectious Diseases,9 University of Pittsburgh Medical Center, Pittsburgh,Pennsylvania, USA; Division of Nephrology,10 Hospital Juan Canalejo, A Coru a, Spain; Division ofNephrology,11 Hospital General de Zona #2, Instituto Mexicano del Seguro Social, Hermosillo, Mexico;Pediatric Nephrology Division,12 University Children s Hospital, Heidelberg, Germany; RenalDialysis Treatment,13 Manchester Royal Infirmary, Manchester, United KingdomThe authors are the members of the ISPD Ad Hoc Advisory Com-mittee on Peritoneal Dialysis Related Infections. The guide-lines have been approved by the ISPD Committee on Standardsand Education, chaired by Isaac to: B. Piraino, University of Pittsburgh,Suite 200, 3504 Fifth Avenue, Pittsburgh, Pennsylvania 10 November 2004; accepted 17 January remains a leading complication of perito-neal dialysis (PD).
3 It contributes to technique fail-ure and hospitalization, and sometimes is associatedwith death of the patient. Severe and prolonged perito-nitis can lead to peritoneal membrane failure. Therefore,the PD community continues to focus attention on pre-vention and treatment of PD-related infections (1 8).Guidelines under the auspices of the InternationalSociety for Peritoneal Dialysis (ISPD) were first publishedin 1983 and revised in 1989, 1993, 1996, and 2000(9 11). The initial focus was on the treatment of perito-nitis, but the more recent guidelines included sectionson preventing peritonitis. In the present guidelines, theCommittee has expanded the section on prevention sinceprevention of peritonitis is one of the keys to successwith present recommendations are organized into fivesections:1.
4 Prevention of PD-related infections2. Exit-site and tunnel infections3. Initial presentation and management of peritonitis4. Subsequent management of peritonitis (organismspecific)5. Future researchThese guidelines are evidence based where such evi-dence exists. The bibliography is not intended to be com-prehensive as there have been over 9000 references toperitonitis in PD patients published since 1966. The Com-mittee has chosen to include articles that are considered108 PIRAINO et 2005 VOL. 25, NO. 2 PDIkey references. Guidelines are not based solely on ran-domized controlled trials, as such studies in PD patientsare limited. If there is no definitive evidence but thegroup feels there is sufficient experience to suggest acertain approach, this is indicated as opinion based.
5 The guidelines are not meant to be implemented in everysituation but are recommendations only. Each centershould examine its own pattern of infection, causativeorganisms, and sensitivities, and adapt the protocols asnecessary for local members of the Advisory Committee were care-fully selected. First, nephrologists widely published onPD infections were chosen from around the world, withparticular attention to including nephrologists fromAsia, where the use of PD is growing very rapidly. Sec-ond, members were appointed with expertise in micro-biology (Kuijper), pharmacotherapy ( bailie ), infectiousdiseases (Paterson), and immunology (Holmes). The cur-rent guidelines are for adults only, as pediatric guide-lines are published separately but, for coordination, apediatrician was added to the work group (Schaefer).
6 Third, two nurses (Bernardini and Uttley) represent thevery important role of the nurse in the prevention of PDinfections and care for PD patients with OF PD-RELATED INFECTIONS Every effort should be made in each PD program toprevent peritonitis to optimize outcomes on PD. Everyprogram should monitor infection rates, at a mini-mum, on a yearly basis (Opinion) (12 14).Programs should carefully monitor all PD-related in-fections, both exit-site infections and peritonitis, includ-ing the presumed cause and cultured organisms, as partof a continuous quality improvement program. The fre-quency of relapsing peritonitis also must be each peritonitis episode, a root cause analysis shouldbe done to determine the etiology, and, whenever pos-sible, an intervention made to prevent another may involve review of the patient s technique.
7 Ifnecessary, retraining should be performed; this shouldbe done only by an experienced PD nurse. Causative or-ganisms and presumed etiology must be reviewed in aregular fashion by the PD team, including both the homenurses and the physician(s), and, if appropriate, the phy-sician assistant or nurse practitioner. In this way, inter-ventions can be implemented if infection rates are risingor unacceptably high. Table 1 provides an easy methodto calculate infection rates. Infection rates for individualorganisms should also be calculated and compared to theliterature. The center s peritonitis rate should be no morethan 1 episode every 18 months ( per year at risk),although the rate achieved will depend to some extenton the patient population.
8 However, overall rates as lowas to have been reported, a goal that cen-ters should strive to achieve (15,16).The type of PD used may have an impact on the fre-quency of infection. Patients on nightly PD (cycler atnight with a dry day) may have a decreased risk of infec-tion compared to continuous cycling peritoneal dialysis(CCPD; cycler at night plus day fill), perhaps because theempty abdomen for part of the day enhances immunefunction (17). The literature describing the relative risksof peritonitis with CCPD versus continuous ambulatoryperitoneal dialysis (CAPD) is conflicting. Several stud-ies have shown that CCPD patients have significantlylower peritonitis rates than CAPD patients (18 22). How-ever, use of a cycler that requires spiking may lead tohigh rates of peritonitis due to contamination if an as-sist device is not used.
9 The Committee recommends theuse of an assist device for all spiking procedures. Somecyclers require a cassette; if reused, there is a high riskof peritonitis with water-borne organisms. Cassettesshould not be reused (23,24). More research is neededcomparing peritonitis risk with dry day, CCPD, and PLACEMENT No particular catheter has been definitively shown tobe better than the standard silicon Tenckhoff cath-eter for prevention of peritonitis (Evidence) (25 35). Prophylactic antibiotics administered at the time ofinsertion decrease infection risk (Evidence) (36 39).Ideally, the patient should see the surgeon and/ortraining nurse prior to catheter placement, and the ideallocation for the exit site determined. In addition, theTABLE 1 Methods for Examining Peritoneal Dialysis-Related Infec-tions (Peritonitis, Exit-Site Infections) Ref.
10 (14)1. As rates (calculated for all infections and each organism):a. Number of infections by organism for a time period, di-vided by dialysis-years time at risk, and expressed asepisodes per yearb. Months of peritoneal dialysis at risk, divided by numberof episodes, and expressed as interval in months be-tween episodes2. As percentage of patients per period of time who are peri-tonitis free3. As median peritonitis rate for the program:a. Calculate peritonitis rate for each patientb. Obtain the median of these rates109 PDIMARCH 2005 VOL. 25, NO. 2PD-RELATED INFECTIONS RECOMMENDATIONS patient should be free of constipation. A single dose ofintravenous (IV) antibiotic given at the time of catheterplacement decreases the risk of subsequent infection.
